Healthcare Provider Details

I. General information

NPI: 1073592275
Provider Name (Legal Business Name): MID-SOUTH PULMONARY SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 POPLAR AVE SUITE 800
MEMPHIS TN
38157-0101
US

IV. Provider business mailing address

5050 POPLAR AVE SUITE 800
MEMPHIS TN
38157-0101
US

V. Phone/Fax

Practice location:
  • Phone: 901-276-2662
  • Fax: 901-274-1871
Mailing address:
  • Phone: 901-276-2662
  • Fax: 901-274-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY WEIS AVERY
Title or Position: ADMINISTRATOR
Credential: JD
Phone: 901-333-8443